Provider First Line Business Practice Location Address:
4550 38TH AVE SW APT 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98126-2770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-260-9814
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2026